Crushing Bundled Payments: 10 Critical Program Elements

February 14, 2019October 31, 2019

by Jason McCormick Vice President, Partner Services at Fusion5

One of the first lessons I learned regarding bundled payments was that everyone had a different definition of the term. To some, bundled payments refer to the proactive payment for a set of services that are provided to a patient, while others may be more in line with the CMS definition of bundled payments, which refers to a retrospective review of performance compared to a target price. Regardless of your accepted definition, bundled payments are one of the mechanisms that are being used to reimburse providers for services rendered in an effort to reduce health care expenditures.

As with most anything in life, those that “get it” have an opportunity to be extremely successful and those that struggle with implementing and following through will fall another step behind. A well-designed plan can serve as the foundation for a successful bundled payment program and ensure that strategies are in place to address any complications. Here’s a list of the ten program elements that have proven to offer stability and helped maximize the financial opportunity that these types of programs offer.

1. Data Review – Usually this review is going to be based on claims data, but there is plenty available to identify opportunities. Not only does the data review help identify opportunities, it helps to identify those services or providers that are not delivering value or quality care.

2. Identify & Engage Preferred Provider Network– Once your review of data is complete, you will have a good idea of those providers that offer the quality of care you desire and what type of value they will bring to your program. Next step is to engage those providers to create a partnership network.

3. Establish Protocols & Clear Lines of Communication- Successful bundle programs are all about having protocols in place that can easily be followed. Open lines of communication will ensure that any variance from expected result is discussed and treatment plans addressed.

4. Identify Surgical Candidates Early- This element proves to be valuable time and time again, as there will be more time to prepare the patient and conduct the pre-surgery requirements, such as medical clearance. Early identification also helps plan patient needs once they move into the post-acute period.

5. Scheduling Prehab and Outpatient Physical Therapy – Pre-surgcal participation in a prehab program has shown to improve outcomes, as patients are taught exercises to increase range of motion and to maintain strength. Having outpatient appointments scheduled prior to surgery prevents patients from being overwhelmed with details the day after surgery.

6. Conduct Risk Assessment with Patient – Conducting a pre-surgical risk assessment allows for potential issues to be identified and addressed before surgery and before they require extensive or unplanned resources. Many issues can be dealt with in a medical management setting prior to surgery if they are identified early.

7. Setting Patient Expectations – This element may have the largest potential to impact cost and prevent last-minute decisions, which can lead to utilization of unplanned resources. Everyone associated with the patient from the time they are identified as surgical candidates should be involved in setting the patient’s expectations.

8. Managing Behaviors – If setting patient expectations is the most important factor, managing behaviors is the second. Program coordinators need to be prepared to manage the behaviors of everyone involved in the process, including the patients, physicians, and partnering post-acute facilities and/or service providers.

9. Care in the Post-Acute World – If the episode period for the bundled payment program extends past the surgical event, you have to be prepared to remain involved in the patient’s care once they move into the post-acute period. The post-acute period can include inpatient rehab facilities, skilled nursing facilities, transitional living, home health services, outpatient physical therapy services, or any other service provider.

10. Establish Strategies for Addressing Potential Readmissions – Regardless of the best-planned program, unfavorable outcomes will happen. Establishing strategies for how providers will deal with patient questions and/or concerns can prevent an unnecessary emergency room visit or a readmission that could have been addressed by answering a patient question.

These elements have proven to be extremely valuable in the creation and maintenance of bundled payment programs, both in inpatient and outpatient settings. While these elements may carry different weight in each type of bundled payment program, successful programs will have each of the elements in place to some degree. Regardless of ownership or management structure, implementing these elements is possible. The basic requirements will prove to be the building blocks that you can fall back on when things need to be reassessed.

This is the first in a series of articles that will provide additional thoughts and tactics on what can be accomplished by implementing each of these program elements. We will look into how each element can be added and what actions can be taken to ensure the element becomes a program fundamental. These fundamentals will help your practice take advantage of every model put in front of you and help you crush bundled payments.

PETER LOUGEE

Senior VP OF Partner Solutions

Peter is a nationally recognized expert on post-acute and value based care. He has held multiple executive positions in operations, sales, and business development, and spent more than twelve years serving as a senior executive at one of the largest nursing home providers in the country. His experience also includes leading the largest skilled nursing company in Texas through the first version of BPCI.

Peter is a proud Texan and graduated from Southern New Hampshire University with a degree in Marketing.

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REMAY

CHIEF HAPPINESS OFFICER

As Chief Happiness Officer, Remay puts the “fun” in functional. Her exuberance and sweet nature bring out the best in the team. She rarely takes no for an answer, and takes charge of getting her colleagues out of their chairs and into the fresh air for regular walking meetings.

She has a Pawchelors Degree in Fetch and is currently working on her PhDog in Lawn Leadership. Remay takes pride in her ability to make anyone smile, and has yet to meet a squirrel she won’t chase.

DAN PAQUIN

CHIEF STRATEGY OFFICER

Dan has significant experience in the healthcare sector, including considerable experience with the Centers for Medicare & Medicaid Services (CMS), including the development of the original Bundled Payment for Care Improvement (BPCI) initiative. He is a widely recognized expert on government healthcare programs, having implemented long-term-care Medicaid programs for the states of Kentucky and Florida.

Dan is also considered an expert in the management and financial performance of Managed Care Organizations (MCOs), and is responsible for developing and implementing corporate strategy at Fusion5.

KATHY KRESS

CHIEF FINANCIAL OFFICER

Kathy has served as a senior financial executive at some of the largest companies in the United States. She is considered an expert in mergers and acquisitions (M&A), corporate strategy development, capital markets, and business restructuring. As a divisional financial leader for Walmart, Kathy was charged with the financial performance of the company’s Consumer, Health and Wellness business.

Kathy earned her MBA from the Stephen M. Ross School of Business at the University of Michigan.

MICHAEL J. LEVOSHKO

CHIEF INFORMATION OFFICER

Mike has more than 25 years of experience as a value based care entrepreneur and innovator. He has held leadership positions in managed care and behavioral healthcare organizations serving the public, private, and employer group sectors. He is also the co-founder and Chief Technology Officer of Senior Whole Health, which was named the fastest-growing privately held company in the United States by Inc. magazine.

Mike studied Mechanical Engineering at Northeastern University and is widely recognized as one of the nation’s foremost thought leaders on healthcare technology.

DENISE GALLAGHER

CHIEF OPERATING OFFICER

Denise has a proven track record of healthcare innovation and entrepreneurship and has served in leadership positions at Aetna, Coventry, AmeriGroup, and AmeriChoice. Her work in healthcare innovation has taken her from Alaska to Massachusetts, and she was instrumental in the success of NHP of Rhode Island, the first Federally Qualified Health Center (FQHC) in the nation.

Denise is also the co-founder of Senior Whole Health, named by Inc. magazine as the fastest- growing privately held company in the United States.

GERALD RUPP, PHD

CHIEF INNOVATION OFFICER

Jerry is a healthcare executive, innovator, and educator with more than two decades of experience developing and administering healthcare-delivery and payment-model reform, including bundled payments. Additionally, Jerry served in an advocacy role at the Centers for Medicare and Medicaid Services (CMS), and was the Executive Director and Vice President of Research at the Institute for Science and Health.

Jerry has served as a professor of anatomy and has authored over 30 peer-reviewed articles. He received his PhD in cell biology and anatomical sciences from SUNY – Buffalo.

SUE CAITO

CHIEF CLINICAL OFFICER

Sue brings over 25 years of clinical experience to the world of value based care, bundled payments, and BPCI. Her focus on innovation resulted in the successful development of a BPCI case-management program within a multi-disciplinary practice that led to measurable improvement in quality outcomes for more than 50,000 Medicare orthopedic patients.

Sue is the author of multiple published articles on readmissions reduction and graduated from Webster University with her degree in nursing.

JAMES GERA

CHIEF EXECUTIVE OFFICER

Jim is a proven innovator and value based care entrepreneur. Prior to serving as CEO of Fusion5, Jim achieved remarkable results as a senior executive at several healthcare organizations. Over the past several years, Jim has focused on programs and opportunities within healthcare reform and has served as chairperson for several CMMI grant reviews.

Jim is also an accomplished musician and received his MBA from the Southern Illinois University at Edwardsville.